Ethical Motivation in Terms of Developmental Stages

Much attention has been paid to ethics in the national news coverage of the recent Senate confirmation hearings. It reminds us that there is a range of ethical behavior, including concerns about conflicts of interest, dual relationships, and the establishment of boundaries. These ethical challenges are no less relevant to physicians, so a review of a psychological theory of moral development may be helpful.

Lawrence Kohlberg was an American psychologist who adapted Jean Piaget’s theory of psychological development over the lifespan to address the question of moral development. He conceived a model with six stages of development according to how individuals justify their actions. The stages are subdivided into three levels: Preconventional, Conventional, and Postconventional. These levels may be used to examine the ethical developmental level of our own and others’ decisions and to identify the standards expected of physicians.

The Preconventional level encompasses the first two developmental stages: Punishment and Obedience, and Instrumental Relativist. In the Punishment and Obedience stage, an action is judged morally good if it doesn’t result in punishment. Think of a young child taking another child’s toy: if he’s not punished, taking the toy must not have been wrong. In the Instrumental Relativist stage, the child learns to get what he wants through negotiation, such as a brother agreeing to share his toys with his sister in exchange for a cookie. The child is learning morally good behavior, but the motivation is egocentric: getting a cookie. This is much like a physician accepting a lavish gift from a pharmaceutical company in exchange for prescribing that company’s product. This Preconventional morality is inappropriate in medicine.

The Conventional level of moral development includes the stages of Interpersonal Concordance and Law and Order. In the first of these, good actions are those that please others, resulting in a “good boy” or “good girl” affirmation. At the Law and Order level, the individual is motivated to obey the rules and respect authority. Viewed from one perspective, these may seem adequate for a well-functioning society when people are choosing actions that please others and follow the rules. However, the Law and Order level of morality has limitations: if a rule can be circumvented via a loophole or ambiguity, the individual may feel his or her actions are ethically acceptable, while others may disagree. The public should not tolerate a physician exploiting a loophole concerning professionalism.

The Postconventional level of moral development involves the stages of Social Contract and Universal Ethical Principles. In the Social Contract stage, the individual is oriented toward the greater good and right action according to society’s standards. This is the motivation for people to perform altruistic behaviors, such as picking up trash they find on the ground even if they didn’t put it there.

In the stage of Universal Ethical Principles, individuals are motivated by abstract principles of justice and respect for human dignity. Actions stemming from this stage include volunteering to serve in human rights organizations, participation in civil disobedience for a noble cause, or similar selfless acts designed to help others and that confer no benefit to the person taking the action. A physician operating at the level of Universal Ethical Principles practices medicine according to his or her conscience about what is best for the patient, the health of the public, and the needs of the profession. An example of this is the pediatrician working who is working with an undocumented immigrant with a congenital heart defect and devotes uncompensated hours to identify a hospital willing to provide pro-bono surgical treatment to the child.

The pressures and standards of physicians’ professional roles tend to push us toward greater moral development. The burden of being held to a higher standard is also a privilege. Because we are forced to think about public health and allocation of scarce resources, for example, we are encouraged to think beyond the Conventional level of morality. However, even as we aspire to make our decisions from a principled level of morality, many of us are vulnerable to moving back and forth among the stages, particularly if our personal and professional moralities are not in alignment.

As we observe what happens on the political stage, let us be reminded to be morally exacting of ourselves to maintain the highest ethical ideals and behavior. ■